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Paraphimosis

Paraphimosis occurs when the fold of skin that covers the head (glans) of an uncircumcised penis (i.e., the foreskin) has been retracted and narrows below the glans, constricting the lymphatic drainage and causing the glans to swell. If not corrected, blood flow in the penis becomes impeded by the increasingly constricting band of foreskin, which causes further swelling of the glans. Because lack of oxygen from the reduced blood flow can cause tissue death (necrosis), paraphimosis is considered a medical emergency and requires immediate treatment.

What is paraphimosis?

Paraphimosis (say: "para-fim-oh-sus") is a serious condition that can happen only in men and boys who haven't been circumcised. Paraphimosis means the foreskin is stuck behind the head of the penis and can't be pulled back down into a normal position.

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What Causes Paraphimosis?

Uncircumcised men sometimes pull the foreskin back during sex, when they go to the bathroom or when they clean their penises. Doctors and nurses might pull the foreskin back when they examine the penis or put in a catheter.

Causes

Causes include the following:

  • Bacterial infection (e.g., balanoposthitis)
  • Catheterization (i.e., if the foreskin is not returned to its original position after a urethral catheter is inserted, the glans may become swollen, which can initiate paraphimosis)
  • Poor hygiene
  • Swelling-producing injury
  • Vigorous sexual intercourse

Sometimes you, a doctor or a nurse might forget to pull the foreskin back down. If the foreskin is left behind the head of the penis too long, your penis might swell so much that the foreskin is trapped behind it.

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What can I do to Avoid Getting Paraphimosis?

  • After having sex, going to the bathroom or cleaning yourself, be sure to pull the foreskin back down to its natural position.
  • Never leave the foreskin behind the head of your penis for any longer than you need to.
  • If a catheter is put into your bladder, check afterward to be sure that the foreskin is covering the head of your penis.

What Happens if I Get Paraphimosis?

Paraphimosis usually causes pain in your penis, but not always. You might get an infection in your penis. You might not be able to go to the bathroom at all. If you can't pull your foreskin over the head of your penis, you need to call your doctor right away.

The first thing your doctor will do is treat the swelling. This can be done by pressing your penis with a hand or by wrapping your penis in a tight bandage. After the swelling has gone away, your doctor should be able to pull the foreskin back down. If the foreskin remains stuck, your doctor might need to make a small cut in the trapped foreskin to loosen it.

Signs & Symptoms

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Symptoms include the following:

  • Band of retracted foreskin tissue beneath the glans
  • Black tissue on the glans (indicates necrosis)
  • Inability to urinate (urinary retention)
  • Penile pain
  • Redness (erythema)
  • Swollen glans (the shaft of the penis is not swollen)
  • Tenderness

When the foreskin is retracted it usually slips back over the glans, or head of the penis, if the penis is not erect. Sometimes the foreskin remains retracted, restricting the flow of blood out from the glans. This causes swelling, and the ring of tissue that keeps the foreskin from slipping back over the glans tightens even more. If the foreskin is left in a retracted position long enough, the painful swelling known as paraphimosis can result.

Complications

Tissue death caused by loss of blood supply (gangrene) and spontaneous detachment of diseased tissue (autoamputation) of the glans are possible complications of paraphimosis.

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Care

Sometimes the foreskin can be worked back into place manually. However, the doctor may need to make a slit in the foreskin to relieve the pressure. Removal of the foreskin (circumcision) is often recommended.

WHAT YOU SHOULD DO

·         If the doctor slits the foreskin, keep the dressing clean and dry and leave it in place until you return to the doctor.

·         Apply ice packs to the penis to reduce swelling.

·         You may take over-the-counter pain medicines such as aspirin, acetaminophen, or ibuprofen. You doctor may prescribe additional medication.

·         Do not try to pull back the foreskin until after your follow-up visit.

·         Avoid sexual intercourse for 7 to 10 days.

·         In uncircumcised babies, the foreskin is normally tight. It usually doesn't start to loosen enough to be pulled back until the baby is at least 18 months old. Until then, leave the foreskin alone. Later, you may gently pull back the foreskin during bathing.

Call Your Doctor If...

·         The pain gets worse.

·         The foreskin stays swollen for 24 hours, or the swelling gets worse.

·         You have increasing redness, swelling, or drainage from the area. These are signs of infection.  

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Seek Care Immediately If...

·         You are unable to urinate.

·         You develop severe pain.

·         You have bleeding from the area that will not stop with gentle pressure.

·         You have a high temperature.

 Incidence & Prevalence

In the United States, paraphimosis occurs in about 1% of males over age 16. It can occur at any age but is most common during adolescence. Paraphimosis occurs in the elderly who need frequent catheterizations and those who have a history of poor hygiene or bacterial infections.

Risk Factors

Uncircumcised males are at risk. Piercing the penis increases the risk if the penile ring interferes with foreskin retraction or replacement over the glans, and if infection results from the piercing.

How to Bring it Back

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What is Going on in the Body? 

You can probably bring your foreskin back yourself. The procedure is very like getting a tight ring off your finger. The essence of getting the glans back through the foreskin is not stretching the foreskin, but compressing the glans. Gently squeezing it and pushing it with your thumbs will press the blood back down the penis and make it smaller. It can then be pushed back through the narrowest part of your foreskin. A drop or two of something slippery like cooking oil or sexual lubricant on the glans may help.

If the patient is a child, the person reducing the paraphimosis by this method needs to know that the process will hurt, but only momentarily.

One good way to reduce the swelling is by covering the penis in ordinary (granulated) sugar. This draws the fluid out of the penis by osmosis (the old high school water-through-a-membrane trick).

If this fails, it is important to see a doctor. S/he can draw off the fluid with a hypodermic needle or, as a last resort, cut through the tight band.

Recently another method has been recommended, the "Dundee technique". This involves pricking the swollen prepuce about 20 times (under anaesthetic) and letting the fluid escape.

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The doctor may then recommend circumcision or try to order it, maybe telling you tales of necrosis, gangrene and autoamputation ("You penis will fall off!") to scare you into it. Circumcision will remove any chance of this happening again. But if the doctor has put a slit in your foreskin, that is probably enough and it won't happen again. Otherwise, it's up to you whether you think you can trust yourself to act in time next time - as you did this time. You're hardly likely not to notice that your foreskin is retracted. It also depends how much you value your foreskin.

The commonest cause of paraphimosis is iatrogenic (doctor-caused), when a catheter (drainage tube) is put in your penis and your foreskin is not brought forward again - probably because the doctor or nurse is unfamiliar with the normal foreskin. The catheter pushing out from inside and the foreskin constricting from outside combine to produce the paraphimosis. The catheter needs to be removed before the paraphimosis is reduced. No catheter, no paraphimosis, and no need for circumcision. The catheter can be put back, the foreskin pulled forwards and paraphimosis will not occur again.

Treatmnet

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